System for communication of health care data

ABSTRACT

An apparatus for communicating health care data from a sender to a receiver is provided. The apparatus has a first computer system, a second computer system, and a rules engine. The first computer system has health care data stored therein. The second computer system is in operable communication with, and is configured to extract the health care data from, the first computer system. The rules engine normalizes the extracted health care data to a predefined format.

RELATED APPLICATION

The present application is a continuation application of and claimspriority to U.S. patent application Ser. No. 10/381,158 filed Mar. 21,2003, entitled “System for Communication of Health Care Data” whichclaims priority to PCT Application No. PCT/US01/42618 filed Oct. 11,2001, entitled “System for Communication of Health Care Data” whichclaims priority to U.S. Provisional Patent Application Ser. No.60/239,860, filed Oct. 11, 2000, entitled “Apparatus and Method forEstablishing Connectivity.” To the extent not included below, thesubject matter disclosed in this application is hereby expresslyincorporated into the present application.

FIELD OF THE INVENTION

The present invention relates generally to a computerized system thatestablishes connectivity between interested parties in the health careindustry for the administration of health care services. Moreparticularly, the present invention relates to a system for thenormalization of health care data of various formats and exchanging thedata in normalized form between insurers and participants, such asproviders, patients, and employers.

BACKGROUND AND SUMMARY

Health care can be defined as an information industry; most of the timeand money spent in procuring and delivering health care is spentcreating, retrieving, or using information. Expenditures on health careinformation technology support, for example, have increased from aboutone billion dollars in 1990 to a projected $20 billion in 2000. Yet,even with these investments, it is believed that almost half of allcurrent health care expenditures continue to be for non-patient careactivities; a major share of which is for non-automated informationsupport.

Resources having to be directed to non-patient care activities have beenendemic in the health care industry since the 1960's. During the 1990's,however, with the demise of Medicare Cost Reimbursement and the rise ofmanaged care, there has been a major shift in attitude and focus amongboth physicians and patients. New rules now govern the delivery ofmedical care and the payment for such care. Whether via preferredprovider arrangements, capitation arrangements of endless variety, casemanagement, or “best practice” enforcement, determining what care isallowed, what will be paid by whom, and making sure that the appropriateinformation is submitted to ensure that the process works are nowconsuming a major share of both time and financial resources ofinsurers, providers, and patients.

Health care participants, like providers and employers, regularly dealwith a number of health care plans from various health insurers. Theseparticipants, however, can only obtain information from the insurancecompanies in limited ways, often making the acquisition of suchinformation quite burdensome. Participants usually only have thetelephone, fax, or letter available as a means of communication with theinsurers.

Particularly vexing is the timely availability of information frominsurers regarding financial transactions, such as eligibility, claims,and benefits, and basic patient-related information, such as medicaltests and prescriptions. For example, a provider may seek informationfrom an insurer via a submission form or telephone call to that insurer.In many cases, however, such information is sought or received after thecare has been delivered and the patient has left the provider's office.This may result in the delivery of services that are not authorized orcovered by the patient's insurer, or may result in other consequencesthat might impact the type or cost of the services provided.

Another reason for these difficulties is the recent expansion of the“payor” community. At one time, payors consisted of the government (bothfederal and state) and large insurance companies. Now, a complex arrayof self-insured plans, IDN's, IPA's, and PPO's, undertaking full orpartial capitation, insurance carve-outs, and the like have radicallyincreased the number of users of, and the need for, current informationregarding insureds. Most of these entities, both small and large, dospend considerable sums on information systems. Yet, because of theextent of manual processing that exists despite these systems, costs perclaim remain substantial.

In addition, payors incur the wrath of their providers and patients bydesigning complex rules that are difficult or perceived as impossible toadminister or follow. Though contrary to this perception, payors do havean interest in providing timely information to providers, patients,employers, and other participants. Still, a significant percentage of aprovider's claims are rejected often because they do not comply with allof the rules. These claims require resubmission, telephone calls, andother expensive manual interventions. The dollar costs for this currentprocessing scheme are high. In fact, an entire clearinghouse industryhas been developed to provide eligibility (but not benefits)verification services to providers for a fee. Many of the requestedverifications, however, cannot be performed at all by suchclearinghouses, and those that are performed are often unacceptablycumbersome and, thus, too expensive.

Referral authorizations are often even more complex than claims and suchauthorization services are generally not available via traditionalclearinghouses. Each time a provider writes a prescription, for example,it is written against a formulary specific to that patient's health careplan established by their insurer. Because there are so manyformularies, drug prescriptions, too, are often rejected for payment,causing additional work for both the provider and the patient.Similarly, medical tests must be sent to laboratories contracted tosupport a particular plan, and are reimbursed only when matching complexmedical necessity rules.

Many providers do have practice management systems that track encountersand manages billing. None of these systems, however, have thesophistication to accomplish the task of providing all of theinformation from all the various health insurers in such a cogent formthat can be useful to the provider.

Not only providers, but patients, too, spend a majority of their timeinteracting with the health care system engaged in non-health careactivities. This “wasted” time is virtually all related to schedulingappropriate interventions, to waiting for information or services, or toobtaining authorization, reimbursement, or other information for desiredor required health care.

The internet has emerged as a major source of health care informationfor the public. A substantial portion of internet users use it forhealth care information or management. Specifically, patients search theinternet for medical information and answers related to their area ofconcern. In fact, it is becoming common for a patient to enter aphysician's office armed with printouts and long lists of questions andrecommendations from web pages on the internet.

Unfortunately, even with the connectivity the internet provides,information exchange between insurers and patients is lacking. Most ofthe information available to patients from their insurer is on anautomated basis from databases related to either general health careliterature or to specific normality support groups. A critical aspect ofthe patient's health care program, however, is not only knowledge of thenormality or support groups, but also what their insurer's health careplan provides as treatment options for that normality, eligibilityinformation, referral authorization, claim submission and payment,testing, and medications. As discussed, these functionalities are toocomplicated for the current system to handle in an automatedenvironment. Personally-referenced information linked to an individualpatient's provider and health care plan is generally unavailable,because that data exists in several databases often each in a different,incompatible format, requiring human intervention to extract and processthe data. The patient's current solution is, thus, an endless number oftelephone calls at a high cost in dollars, time, and frustration.

A reason for such incompatibility is that each database served theindividual needs of those using the data before such a time whenconnectivity between databases was a consideration. The consequence ofhaving different databases of different formats is that it is notpossible to provide a central repository of homogenized data readable byany variety of computers. It is this incompatibility that prevents widespread connectivity between insurers and participants.

Transliterating and interfacing programs are known in the art. Programsthat take data in one format can be translated and read by a computer ofa different format. Such transliterating, however, only shifts data froma field of an incompatible format to a target field of a new format. Itcannot determine whether the data of the incompatible format is beingtransferred to the correct target field. Normalization or remodeling ofthe data not only transfers the data, but also determines the meaning ofthe data and puts that data in the correct field.

It would, therefore, be beneficial to provide a system with whichinsurers may communicate with providers, patients, etc., to provideinformation about a particular health care plan either before, orcontemporaneously with, the patient's visit to the provider, regardlessthe lack of compatibility of the databases. It would be furtherbeneficial if this system of communication spanned a variety of insurersso the provider, for example, may communicate with any plan in which thepatient participates. It would also be beneficial for providers to havean automated system of determining eligibility and benefits, receivingauthorizations and pre-certifications, submitting claims, obtainingreimbursements, and adjudicating claim problems through thenormalization of data of the incompatible databases.

Accordingly, an illustrative embodiment of the present disclosureprovides an apparatus for communicating health care data from a senderto a receiver. The apparatus comprises a first computer system, a secondcomputer system, and a rules engine. The first computer system havinghealth care data stored therein. The second computer system is inoperable communication with, and is configured to extract the healthcare data from the first computer system. The rules engine normalizesthe extracted health care data to a predefined format. The rules enginedefines a plurality of health care data fields in the predefined format,as well as a plurality of relationships between fields of normalizeddata.

Further embodiments may include the first computer being a plurality ofcomputers each having portions of the health care data stored thereon.The apparatus may also comprise a third computer system, in operablecommunication with, and configured to receive the normalized data from,the second computer system. The rules engine may determine whether thethird computer is authorized to receive the health care data.

Another illustrative embodiment provides a method for communicatinghealth care data from one computer system to another. The methodcomprises the steps of storing health care data in a first computersystem; extracting health care data from the first computer system andcommunicating the extracted data to a second computer system;normalizing the extracted data to a predefined format in accordance witha rules engine that defines a plurality of health care data fields inthe predefined format and a plurality of relationships between fields ofnormalized data; and communicating the normalized data to a thirdcomputer system.

Further embodiments of the illustrative method may include the firstcomputer system comprising a plurality of computers, wherein the storingstep includes storing health care data in more than one of saidcomputers. Also, the third computer system comprises a plurality ofcomputers. The health care data exists across a plurality of databasessuch that each of the plurality of databases are in operablecommunication with the second computer system.

Another illustrative embodiment provides a system of exchanging healthcare data between a sender and a receiver. The system comprises a sendercomputer, an intermediary computer, a rules engine and a receivercomputer. The sender computer stores the health care data. Theintermediary computer is in operable communication with the sendercomputer and is configured to extract the health care data. Theextracted data is normalized to a predefined format, creating normalizeddata pursuant to a rules engine. The rules engine defines each field ofthe health care data and converts each field to a corresponding field inthe predefined format. The rules engine also defines how the normalizeddata should relate to each other pursuant to predetermined instructions.The receiver computer is in operable communication with the intermediarycomputer. The receiver computer receives the normalized data subjectedto the second rules engine.

Further embodiments may include the sender computer being a plurality ofcomputers each having portions of the health care data stored thereon.The rules engine may determine whether the receiver computer isauthorized to receive the health care data. When the receiver is ahealth care provider, the normalized data exchanged between the senderand receiver may be chosen from a group comprising eligibility/benefitdisplay, member roster, claim submission, provider lookup, formularylookup, diagnosis code lookup, procedure code lookup, access health planinformation online, communicate with a health plan on-line, communicatewith patients on-line, patient-centric view of data across severalhealth plans, order generation and tracking, results review and release,result printing, prescription writing, medication profile for eachpatient, access to patient's personal health record based on patientapproval, personalized medical and health care content integration, bothcontext-specific and on demand, e-commerce integration: office, medicaland health-related product awareness and buying capabilities, email,practice management system subscription, support disease management, andphysician credentialing subscription. When the receiver is an employer,the normalized data exchanged between the sender and receiver is chosenfrom a group comprising group eligibility, group enrollment, enrollmentchanges, formulary lookup, e-commerce integration, access from healthplan web site or direct access via URL, personalized contentintegration, both context-specific and on demand, e-commerce integrationand health care-related product awareness and buying capabilities.

When the receiver is a patient, the normalized data exchanged betweenthe sender and receiver is chosen from a group comprising identificationcard requests, address changes, provider directory inquiries,personalized health information based on an interest profile, diagnosisinformation, relevant articles and patient education materials,communications from health care providers and health care plans, lab andradiology results, scheduled appointments with a health care provider,prescription refills, personal health records, eligibility/benefitinformation, claim information, referral and authorization informationand status, provider lookup, family history, medication profile andformulary lookup.

Another illustrative embodiment of the present invention provides asystem of normalizing health care data for transfer between an insurerand a participant. The system comprises an insurer system, anintermediary system, and a participant system. The insurer system isconfigured to maintain at least one database comprising the health caredata. The intermediary system is operatively connected to the insurersystem and to the database, configured to extract the health care datafrom the database of the insurer system, and store the health care datain a staging database as extracted data. The extracted data isnormalized to a predefined format, creating normalized data pursuant toa rules engine that defines each field of the extracted data in thepredefined format. The rules engine also defines how the normalized datarelates to each other pursuant to predetermined instructions. Theparticipant system is in operable communication with the intermediarysystem, and is configured to receive the normalized data subject to therules engine.

Further embodiments of the illustrative system may include the at leastone database being a plurality of databases, such that the intermediarysystem is operatively connected to the plurality of databases. Inaddition, the participant system may transmit a request that is sent tothe intermediary system that determines which health care data is to beextracted and normalized in order to respond to the request. Theparticipant system may also transmit the request, and the intermediarysystem may transmit the normalized data over the internet. The rulesengine may define the relationships among the normalized data pursuantto predetermined instructions to determine a response to the request.The intermediary system may also comprise an error data system thatremoves extracted data identified as invalid when the extracted data isnormalized. The extracted data identified as invalid is then corrected,reintroduced, and is normalized. The intermediary system may furthercomprise an audit database to track the activity of the intermediarysystem.

Another illustrative embodiment of the present invention provides asystem of health care management of medical testing administrationbetween an insurer, a medical laboratory, and at least one health careparticipant. The system comprises a participant computer, an insurerprocessing system, a rules database, and a laboratory computer. Amedical test request is made at the participant computer pursuant to afirst predetermined format. The insurer processing system is operativelycoupled to the participant's computer, and is through which the medicalrequest is transferred. The processing system is operatively coupled tothe rules database to approve the medical test request pursuant topredetermined criteria. The laboratory computer is operatively coupledto the processing system and receives the medical test request ifapproved by the rules engine. Results of the medical test aretransmitted from the laboratory computer to the processing system. Theresults are further transmitted to an insurer computer that isoperatively coupled to the laboratory computer and to participant'scomputer.

Further embodiments of the illustrative system may include theprocessing system converting the results of the medical test to a secondpredetermined format readable by a database stored on the insurercomputer. In addition, at least one health care participant may bechosen from a group comprising from a health care provider, an employer,and a patient. Furthermore, the medical test request and the results ofthe medical test may be transmitted through the internet.

Additional features and advantages of the system will become apparent tothose skilled in the art upon consideration of the following detaileddescriptions exemplifying the best mode of carrying out the system aspresently perceived.

BRIEF DESCRIPTION OF THE DRAWINGS

The illustrative system will be described hereinafter with reference tothe attached drawings which are given as non-limiting examples only, inwhich:

FIG. 1 is a diagrammatic view of a system for normalization of healthcare data and the exchange of same between several health care insurersand various health care participants;

FIG. 2 is a diagrammatic view of the data processing system for thesystem of normalization shown in FIG. 1;

FIG. 3 is a diagrammatic view of the data extraction and business objectsub-systems for the system of normalization shown in FIG. 1; and

FIG. 4 is a diagrammatic view of a system of health care management formedical testing between health care insurers and participants.

Corresponding reference characters indicate corresponding partsthroughout the several views. The exemplification set out hereinillustrates an embodiment of the invention, and such exemplification isnot to be construed as limiting the scope of the invention in anymanner.

DETAILED DESCRIPTION OF THE DRAWINGS

An illustrative embodiment of the invention, such as that shown in FIG.1, comprises a system 2 which includes a plurality of database sets 4,6, 8 offered by a variety of insurers 11. It is appreciated that eachhealth care database set 4, 6, and 8 represents an insurer's databaseprocessing system or series of processing systems and databases. Forexample, database sets 4, 6, or 8 may each represent a conventionalcomputer system, a server, a local area network (LAN), a legacy, orother computer system storing one or more databases. It is contemplatedthat to transmit data, either the system as it exists is capable ofdoing so, or a system is added to either database sets 4, 6, or 8 toperform this function. It is further contemplated that each of databasesets 4, 6, 8 may represent a single database or a plurality ofdatabases, each of which may be of any variety of database formats orlanguages.

For the purposes of this application, it is contemplated that referenceto the term “insurer,” as used herein for insurers 11, is forillustrative purposes only. Such a term includes health insurancecompanies, but also includes health maintenance organizations,self-insured entities, disease management organizations, capitatedhealth care providers, Medicare agencies, as well as any otherorganization that might store or manage health care data. The term“insurer” is not to be construed as being limited in scope to onlyhealth insurance companies or other “payors.”

Conventionally, health care data is stored on an insurers' computer orseries of computers in several databases, each of which often being in aunique format, with each database format being incompatible with otherdatabase formats. For example, one insurer may have their health caredata stored in one format, and a second insurer may have their healthcare-related data stored in a second format that is not compatible withthe one format. Additionally, and more problematic is that, even withinthe same insurer's 11 system, eligibility data, for example, may existin a database of one particular format, developed to suit the needs ofits users at the time, whereas, the claims data, for example, may bestored in another database in a format that suits the needs of thoseusers, but with its format being incompatible with the format of theeligibility data. In either example, it is contemplated that in thepresent invention, health care data of any format is normalized into acommon format, and distributed through a common network, like internet12, to a health care participant 13, who uses the normalized data toconduct health care-related transactions and tasks. It is furthercontemplated, and to be discussed further herein, that various levels ofaccess and security can be provided to assure that those participants 13accessing the normalized data are authorized to access only that datapredetermined as necessary and appropriate for their particular use orneed.

As FIG. 1 shows, data from each database set 4, 6, 8 can be transmittedto a data processing system 10 that normalizes the data into a formatreadable by particular health care participants 13. More specifically,the data is transmitted over the internet 12, which is operativelyconnected to and read by participants' 13 computer(s) or terminal(s).Such participants 13 illustratively include providers 14, employers 16,and patients 18, or any combination thereof. It is contemplated thatparticipants 13 can further include any other interested party that canrequest data or information from an insurer, including other insurersand disease management organizations, for example.

It is contemplated that the transmission of data from database sets 4,6, or 8 is initiated by any of the participants 13 submitting a request22 through a computer or computers. Request 22 is transmitted throughthe internet 12 to data processing system 10 which retrieves theappropriate data from the appropriate database set or sets of either 4,6, or 8. That data is normalized to a common format, at which point aresponse 24 to the request 22 is made. For example, a health careprovider 14 may place a request 22 on behalf of an insured to authorizepayment for a medical procedure. In this example, it is presumed thatthe data required to formulate a response 24 exists collectively oneligibility, benefits, and claims databases that illustratively exist ondatabase set 4. Data processing system 10, in order to prepare aresponse 24, determines and extracts which data is necessary from thedatabases. System 10 then normalizes the data into a homogenous format,and then determines what the nature of the response should be. In thisexample, response 24 should be to either authorize or deny payment forthe medical procedure. System 10 uses the normalized data to determinethe response, which is then transmitted to provider 14, thus, completingthe transaction. It is contemplated that system 2 may comprise anynumber of insurers 11 or participants 13. Specifically, data processingsystem 10, as will be discussed further herein, is able to connect andmanage transactions between a single or plurality of participants 13with any insurer or plurality of insurers 11.

It is further contemplated that system 2 will provide health careparticipants 13 with a variety of health care transaction optionsreferred to generally in the form of requests 22 and responses 24between participants 13 and insurers 11. Examples of transactionsavailable to health care providers 14 are: eligibility/benefit display,member roster, claim submission, provider lookup, formulary lookup,diagnosis code lookup, procedure code lookup, access health planinformation online, communicate with a health plan on-line, communicatewith patients on-line, patient-centric view of data across severalhealth plans, order generation and tracking, results review and release,result printing, prescription writing, medication profile for eachpatient, access to patient's personal health record based on patientapproval, personalized medical and health care content integration, bothcontext-specific and on demand, e-commerce integration: office, medicaland health-related product awareness and buying capabilities, email,practice management system subscription, support disease management, andphysician credentialing subscription.

As further example, the following are specific records and fields forhealth care transactions between providers 14 and insurers 11 thatutilize normalized data:

Record: Summary

-   -   Fields:        -   Activity for (date)        -   Referrals        -   Claims        -   Test Results        -   Members        -   Update State for Americas Health        -   Benefit Records        -   Claim Records        -   Patient Records        -   Provider Records        -   New Just For You            Record: Eligibility    -   Fields:        -   Today's Patients        -   Patient Search        -   Sex        -   Coordination of benefits        -   Medicare data        -   Add to patient list        -   Name        -   From Date        -   To Date        -   Birth date        -   Member ID        -   Relation        -   PCP        -   Address        -   City        -   State        -   Zip        -   Current Benefit        -   Group        -   Carrier        -   Benefit Plan            Record: Claim Status    -   Fields:        -   Patient Name        -   From Date        -   To Date        -   Claims        -   Claim Number        -   Status        -   Provider Name        -   Patient Name        -   Member Number        -   Billed Amount        -   Patient Responsibility        -   Paid Amount        -   Date of Service            Record: Claim Detail    -   Fields:        -   Member        -   Provider        -   Diagnosis        -   Description        -   Line number        -   DOS        -   CPT        -   Description        -   Modifier        -   Location        -   Units        -   Status        -   Billed        -   Allowed        -   Copay        -   Coinsurance        -   Deductible        -   Paid        -   Totals            Record: Explanation of Payments    -   Fields:        -   Line Number        -   Status Description        -   Explanation        -   Check/Date            Record: Select Specialist    -   Fields:        -   Address        -   City, State, Zip        -   Handicap Access        -   Office Hours        -   Contact        -   Phone        -   Fax Phone        -   Phone After Hours        -   Sex        -   Birth Date        -   Specialty        -   Second Specialty        -   Accept Patient        -   Primary Care        -   Board Cert        -   Languages        -   Hospitals        -   Hospital Privileges        -   Networks            Record: Add claims    -   Fields:        -   Health Insurance        -   Insured's ID Number        -   Patient Last Name        -   First Name        -   Middle Name        -   Patient's Address 1        -   Address 2        -   City        -   State        -   Zip        -   Patient's Phone        -   Birth date        -   Gender        -   Relationship to Insured        -   Marital Status        -   Patient Employment Status        -   Condition Related to Job        -   Con. Rel. to Auto Accident        -   Cond. Rel. to Other Accident        -   Insured's Last Name        -   First Name        -   Middle Name        -   Gender        -   Birth date        -   Insured's Address 1        -   Address 2        -   City        -   State        -   Zip        -   Phone        -   Insured's Group or FECA Number        -   Insured's Employer/School        -   Insured's Insurance Name        -   Referring Physician Name        -   Referring Physician ID        -   Outside lab        -   Outside Lab Charges        -   Medicaid Resub Code        -   Medicaid Orig.        -   Prior Auth. Number        -   Diag Codes        -   Item        -   Date From        -   Date To        -   Place        -   Type        -   Procedure        -   Mod1        -   Mod2        -   DX Ind.        -   Charges        -   Days/Units        -   Patient        -   Provider        -   From Date        -   To Date        -   Diagnosis 1        -   Diagnosis 2        -   Diagnosis 3        -   Diagnosis 4        -   Procedure Line        -   CPT        -   Description        -   Amount        -   Dx pointer        -   Other Errors        -   Total Amount        -   Billed        -   Allowed Amount        -   Copay Amount        -   Withheld Amount        -   Writeoff Amount        -   Predicted Payment            Record: Referral Status    -   Fields:        -   Referral Number        -   Patient (Member ID)        -   Valid from (months)        -   Referred by        -   Referred to        -   Patient List        -   Referred by        -   Referred to        -   Referral Number        -   Status            Record: Add Referrals    -   Fields:        -   Today's Patients        -   Patient Search        -   Specialists        -   Specialist Search        -   Providers        -   Diagnosis        -   Patient        -   Specialists        -   Provider        -   Diagnosis        -   Start Date        -   Months Valid        -   Visits Requested        -   Reason            Record: Procedure and Diagnosis Data    -   Fields:        -   Diag Number        -   Diagnosis Name        -   Proc Code        -   Procedure Name        -   Visits Allowed        -   Patient        -   Patient Search        -   Referred to        -   Specialist Search        -   Referred by        -   Diagnosis        -   Start Date        -   Exp Date        -   Visits Requested        -   Remarks        -   Services Requested        -   Authorized Ancillary Services            Record: Diagnosis Codes    -   Fields:        -   Diagnosis Code        -   DX Code        -   Diagnosis Code Description            Record: Procedure Codes    -   Fields:        -   Procedure Codes        -   Procedure Code        -   Procedure Description        -   Age From        -   Age To        -   Sex        -   Location Code            Record: Drug Therapeutic Class Listing    -   Fields:        -   Therapeutic Class        -   Class Description        -   Count of Drugs in this Class            Record: Formulary List by Therapeutic Class    -   Fields:        -   Drug Name        -   Generic Name        -   Drug Class        -   Therapeutic Class        -   NDC            Record: Write Prescription    -   Fields:        -   Today's Patients        -   Patient Search        -   Providers        -   For        -   Medication        -   Dispense        -   Refill        -   Sig: Take        -   Sig: For        -   Instructions        -   Select Pharmacy            Record: Medication Profile    -   Fields:        -   Type        -   Medication        -   Dose        -   Frequency        -   Reason        -   Status            Record: Discontinued Medications    -   Fields:        -   Type        -   Medication        -   Dose        -   Frequency        -   Reason        -   Status            Record: Allergies        -   Allergen        -   Reaction        -   Date Started            Record: Medical Test Orders    -   Fields:        -   Patient ID        -   Patient Name        -   Provide ID        -   Provider Name        -   Location        -   Lab Name        -   Dx        -   Action        -   Battery        -   Test        -   ID        -   Type        -   Volume        -   Date        -   Time        -   Collected By        -   Chemistry        -   Hematology        -   Toxicology/Therapeutics        -   Microbiology/Virology        -   Immunology/Serology        -   Urinalysis/Fluids        -   Procedure        -   When        -   Priority        -   Specimen        -   Alert            Record: Results    -   Fields:        -   Status        -   Order number        -   Test Procedure        -   Alert        -   Order Date        -   Facility        -   Patient        -   Provider        -   Date/Time        -   Procedure        -   Status        -   Indicator        -   Date/Time        -   Performed        -   Specimen Number        -   Type        -   Status        -   Result        -   Value        -   Desired Range

Each field listed above represents data that can exist anywhere ondatabase sets 4, 6, or 8, and be in any format or language. If anyrequest 22 is made which calls up one or more of the above records, dataprocessing system 10 searches, extracts, and normalizes the data so itappears in the correct field in the record. It is appreciated thatprovider 14 may change the data, if necessary, and transmit it backthrough internet 12 and data processing system 10 to be stored on theappropriate database set 4, 6, or 8.

Examples of transactions available to employers 16 are: groupeligibility, group enrollment, enrollment changes, formulary lookup,e-commerce integration, access from health plan web site or directaccess via URL, personalized content integration, both context-specificand on demand, e-commerce integration: human resource, business (e.g.,office supplies) and health care-related product awareness and buyingcapabilities.

Again, as a further example, the following are specific records andfields for health care transactions between employers 16 and insurers 11that utilize normalized data:

Record: Open Enrollment

-   -   Fields:        -   Health Insurance        -   Employer Group Number        -   Last Name        -   First Name        -   Middle Name        -   Employee Address 1        -   Address 2        -   City        -   State        -   Zip        -   Home Phone        -   Work Phone        -   Primary Language        -   Birth date        -   Gender        -   Social Security Number        -   Primary Care Physician        -   Established Patient        -   Dependent Last Name        -   First Name        -   Middle Initial        -   Birth date        -   Gender        -   Relationship        -   Social Security Number        -   Primary Care Physician        -   Established Patient        -   Effective Date        -   Hire/Rehire Date        -   Other Health Care Policy        -   Name and Address of Insurer        -   Effective date of other coverage        -   Policy Holder's Last Name        -   First Name        -   Middle Name        -   Policy/Group Number        -   Covered by Medicare        -   Medicare Number(s)        -   Health insurance within the last 18 months        -   If yes, type of coverage: group, individual, COBRA,            Medicare/Champus, Conversion or Other        -   Reason coverage was terminated        -   Read and Agree to Authorization Statement            Record: Enrollment-Changes    -   Fields:        -   Health Insurance        -   Employer Group Number        -   Last Name        -   First Name        -   Middle Name        -   Employee Address 1        -   Address 2        -   City        -   State        -   Zip        -   Home Phone        -   Work Phone        -   Primary Language        -   Birth date        -   Gender        -   Social Security Number        -   Primary Care Physician        -   Established Patient        -   Term Member        -   Dependent Last Name        -   First Name        -   Middle Initial        -   Birth date        -   Gender        -   Relationship        -   Social Security Number        -   Primary Care Physician        -   Term Dependent        -   Hire/Rehire Date        -   Effective Date        -   Change Reason        -   Name        -   Enrollment Type        -   Remarks

Examples of transactions available to patients 18 are: identificationcard requests, address changes, provider directory inquiries, andpersonalized health information based on the member's interest profile,as well as diagnosis information from health plan administrative andclinical information, relevant articles and patient education materials,communications from health care providers and health care plans, lab andradiology results to patients online, scheduled appointments with ahealth care provider, referral status, prescription refills, educationmaterials, personal health records so it can be maintained in his or hercomprehensive health history online for physician reference, vieweligibility/benefit information, view claim information, view referraland authorization information, provider lookup, personal health record,family history, medication profile, formulary lookup, and communicationsbetween member and provider.

The architecture of the data processing system 10 is shown in FIG. 2.Each of the database sets 4, 6, 8 is operatively connected to dataconnectivity sub-system 20. The data connectivity sub-system 20 isconfigured to receive the different types of connections used betweenthe various computer systems which store the database sets 4, 6, 8. Itis appreciated that, in other embodiments, a separate data processingsystem 10 may be provided at the site of each of the database sets 4, 6,8 such that each data processing system 10 is dedicated to manage andnormalize the data, as discussed further herein, as well as manageserver-to-server communications for a single database set.

The data extraction sub-system 28 is also depicted in FIG. 2. Sub-system28 manages the integration of the often plurality of databases. The dataextraction sub-system 28, as further discussed in reference to FIG. 3,also includes logic to manage data access from the several databases ofdatabase sets 4, 6, 8. An enterprise master person index (“EMPI”) 30 isoperatively coupled to data extraction sub-system 28. The EMPI 30presents a cross-database view of all the insureds within system 2. Italso manages the proper identification of providers 14, employers 16,connected patients 18, as well as other entities having uniqueidentities on an as-needed basis. An indices database 32 is supported byEMPI 30. Specifically, the indices database 32 stores indices whichserve as a basis for relating the identification data to each other. Theindices database 32 is typically built upon and maintained by the EMPI30.

The business object sub-system 34 contains the logic rules that drivesthe normalization of data and use of same between insurers 11 andparticipants 13. To provide such capabilities, a variety of processesmay be supported in any particular situation. Illustratively, suchprocesses may include, but are not limited to, rules-based evaluation ofentered data for referral authorizations and admissionpre-certifications; proxy or actual adjudication of claims submitted byproviders, with concomitant delivery of funds to insurers 11 andbenefits explanations to patients 18; sorted lists of providers 14,employers 16, and patients 18; and graphical displays of laboratoryresults and integrated claims-driven health records for patients 18.

The content/e-commerce sub-system 36 adds third party capabilities tothe data processing system 10. The content portion of sub-system 36provides management and integration of third party affiliated content,such as articles about diseases, bulletins, notices, notes, and othermedically-related references. The e-commerce portion of sub-system 36integrates e-commerce capabilities, including business-to-business orbusiness-to-consumer purchasing through shopping cart-type databaseswith affiliated product and service vendors.

The personalization sub-system 38 integrates information from theprevious sub-systems 20, 28, 34, 36 to provide a personalized view ofdata in system 2. Specifically, when any of the participants 13 login tosystem 2 and access data or other information from database sets 4, 6,or 8, or even the content/e-commerce sub-system 36, pertinentinformation derived from the type of content viewed, as well as theproducts purchased or searched, is maintained in a user profile database40. During subsequent logins, therefore, the information a particularuser views can be arranged and accessed in a more familiar, relevant,and useful manner, individual to that participant.

The presentation sub-system 42 manages the normalized data andinformation into a presentable format for participants 13. For example,the world-wide-web, being a popular destination for users of theinternet, accepts output in HTML format, and is accessible by aconventional internet browser. It is appreciated, however, that suchdata may be presented in virtually any form to accommodate differentaccess devices (for example, WAP for mobile devices).

A security sub-system 44 is shown in FIG. 2 integrated with the othersub-systems 20, 28, 34, 36, 38, 42. Security sub-system 44 maintainsdata security in several ways. First, one embodiment contemplates thatthe insurers' 11 data is maintained on its own on-site database, and iscontrolled by the insurers 11. Second, the insurers' 11 data isencrypted when it is routed from the insurers' 11 database to theconnectivity sub-system 20 and, ultimately, the participants 13 when arequest 22 is made. Third, the participants' 13 browser includesencryption to view or send data over the internet 12. Finally, internalsecurity is built into the data processing system 10 to only allow userswith need-to-know access to particular data, such as claims and referralinformation. For example, providers 14 may have access only to claimsand referral information of their insurers, but not individual claimsummaries of their patients. Similarly, the employers 16 may have accessto only their employees' claims information, but not some personalinformation.

An example of an encryption method is the 128 bit Secure Sockets Layer(SSL) with a key certified by VeriSign, Inc. Such SSL encryption meansthat data traveling through the internet and to participants' 13 browsercannot be interpreted by anyone between those two locations. Encryptionis also useful because of the storage of user passwords. There is noplace that a user's password is saved or used by the system astraditional cleartext. From one of the participants' 13 browser throughinternet 12 and to one of the insurers' 11 computer or server, thepassword is protected by SSL. Once the password reaches the finaldestined server, a cryptographic algorithm converts the password to aprotected format. No one, therefore, who has privileged access to theserver or any of the back-end applications, can get any user passwords.

In addition, encryption is useful along the operative connection to aninsurer's 11 database sets 4, 6, or 8 to the data processing system 10.It is contemplated, however, that insurers' 11 computers or servers(database sets 4, 6, or 8) may not need such encryption along thisoperative connection, if the connection is a true point-to-pointconnection. Also, this encryption can be implemented through hardware orsoftware, a virtual private network (VPN), or through the use ofencryption protocols in a database, for example.

There are several modes with which data can be restricted, even withinand among the insurers 11 and participants 13 of system 2. For example,security sub-system 44 may restrict the actual data that a participant13 may request or view from any of insurers 11. A health careorganization, thus, may only view data that they have provided. Forexample, doctors may only view claim data for their own patients.Alternatively, security sub-system 44 may restrict access toparticipants 13 to allow access to only particular fields on aparticular screen of any particular database. For example, if a screenlisted dollar amounts for claims, employers may wish to restrict who isable to view those dollar amounts. Other users, therefore, like patients18, might be able to see the rest of the claims, but not the dollaramounts. Still, further, security sub-system 44 may restrict whichscreens will be accessible to which users. This level of securitydefines which functionality is available to the user. For example, apatient 18 in system 2 may not be able to view the claim submittalscreen submitted by provider 14 at all, but may view a diagnosisinformation or health plan administrative screen. Customizable securitybased on the interests of the user may be included as well. Thissecurity method allows either the insurers 11 or participants 13 to setthe parameters of security for the examples described above. It isfurther contemplated that this tool may be an internet-based tool thatcould add logins to the system, as well as specify values and screensthat a particular user has access to. It is still further contemplatedthat a portion or all of the security measures can be employedthroughout data processing system 12.

An audit sub-system 46, like security sub-system 44, shown in FIG. 2, isalso integrated with the other sub-systems 20, 28, 34, 36, 38, 42. Auditsub-system 46 tracks the operation of all sub-systems. The informationgenerated from audit sub-system 46 allows an administrator to monitorthe operation of system 2 for problems and marketing trends.

A diagrammatic view of the data extraction and business objectsub-systems 28, 34, respectively, is shown in FIG. 3. As previouslydiscussed, the numerous databases represented by database sets 4, 6, 8contain data in a variety of formats. Before the data is transferred toone of the participants 13, however, it is first formatted to a newformat that is readable by any of the computers of participants 13, likeHTML format, for example. The data is, therefore, “extracted” from thedatabase sets, either 4, 6, or 8, and then “normalized” to be read bythe computers of participants 13. The extracted data is indicated byreference numeral 48.

Extracted data 48 from either database sets 4, 6, or 8 is uploaded to astaging database 50 which is typically a portion of data extractionsub-system 28. Rules engine 52 serves a dual purpose of defining therules that control the normalization of the data, as well as how thedata, once normalized, is used. During the normalization process at 54,rules engine 52 homogenizes the data by determining what the data means,then inserting the data into the proper field as normalized data. Rulesengine 52 also remodels the data, if necessary, to a structure orappearance predefined by the normalized format. As a simple example, ina referrals database that may hypothetically exist on database set 6, itmay include the entry “New Jersey” in the state location field. If thatfield is requested by a participant 13, the rules engine 52 will causethat field to be extracted, then determine whether the meaning of thisfield corresponds to the meaning of the normalized state location field,and, if so, then convert the field to the normalized state locationfield at 58. Furthermore, if the rules engine 52 has predetermined thatthe normalized state location field should exist as only a two-characteracronym, then the phrase “New Jersey” will be remodeled to the acronym“NJ.” This is contrasted with traditional transliterating programs thatwould merely match the state location field of the referrals databasewith any field in another database titled “state location field” andthen transfer the data. Such a program cannot determine the meanings ofthe state location fields, and then determine if their meanings matched,as well as not remodel the data to the appropriate appearance. Forexample, a field for laboratory enzymes might be expressed in Celsius inone database and in Fahrenheit in another database. Such data, as wellas countless other data, are typically contextualized by the system theyexist in. Transliterating programs do not compensate for such contextamong data. In the present disclosure, part of the normalization isdetermining the meaning of the data and locating it in a field of thesame definition, but in a single format.

Rules engine 52 also determines whether the data is bad or invalid. Anybad or invalid data that is discovered during the normalization processat 54 is transferred to an invalid data database 56. Invalid data isplaced in database 56 for review and appropriate corrective action and,if appropriate, reintroduced and normalized.

In addition, the rules engine 52 incorporates security 44 to determinewhether the requestor has authorization to view the data that is beingrequested, as previously discussed. For example, if employer 16 requestsclaims data that illustratively exists on database set 8, the rulesengine 52, in conjunction with the security 44, determines whetheremployer 16 has authorization to view the data subject of that request.If not, rules engine 52 would deny fulfillment of the request.

Once the data is converted and remodeled into the normalized format,rules engine 52 determines how the normalized data can be used. Forexample, if a request 22 is made from providers 14 to one of theinsurers 11 to authorize a chest X-ray for one of the patients 18, aproper response 24 may reference data from various eligibility, claims,benefits, and personal data databases which rules engine 52 firstextracts and normalizes. Once the data is normalized, rules engine 52undertakes the process of responding to request 22. Rules engine 52bases response 24 on predetermined rules established by the particularinsurer 11 to determine whether a chest x-ray is an approved procedurein response to the request. It is contemplated that each insurer 11, oreven each database set 4, 6, 8 can be subject to its own unique set ofrules to govern any particular response 24.

An audit database 62, illustrated in FIG. 3, manages and maintainstracking information during the conversion process at 58. All datarequests, responses, and e-commerce submissions can be monitored andrecorded. This audit trail information is maintained in audit database62 to enhance performance and security characteristics. It iscontemplated that audit database 62 can be integrated with auditsub-system 46, as shown in FIG. 2, or database 62 can be a stand-alonesystem working independently or in addition to sub-system 46.

In one embodiment of the disclosure, it is contemplated that system 2will not only exchange information related to insurance and paymentissues, but also provide active management of patient care. For example,as shown in FIG. 4, a portion of system 2 depicts the process formedical tests to be ordered, approved, and results submitted. Forexample, a health care provider 14, via the internet 12, places an orderfor a medical test. The order is transmitted through data processingsystem 10. The order is further transmitted at 72 to a laboratory 70,the order will disclose particular information that will be needed wheneither the specimen or the patient arrives. If a specimen is collectedby provider 14, the order will identify the laboratory 70, and provideinformation to provider 14 so that the specimen may be markedaccordingly before being sent to laboratory 70. Once laboratory 70receives the order and the specimen, laboratory 70 can eithercommunicate the status or results back through data processing system 10to both the provider 14 and the appropriate insurer 13′, as indicated byreference numerals 74, 76, respectfully.

Although the system has been described with reference to particularmeans, materials and embodiments, from the foregoing description, oneskilled in the art can easily ascertain the essential characteristics ofthe illustrative system and various changes and modifications may bemade to adapt the various uses and characteristics without departingfrom the spirit and scope of the present invention as described by theclaims which follow.

1. A system to communicate health care data between a health care payorand a participant, the computer system comprising: an intermediarycomputer system configured to communicate with one or more legacydatabases that store records of health care data and operated by one ormore payor computer systems; wherein the intermediary computer system isconfigured to receive less than all of the health care data associatedwith a health care record from the one or more legacy databases, as aplurality of selected health care data; wherein the plurality ofselected health care data the intermediary computer system is configuredto receive is of a type that each of the plurality of selected healthcare data is displayed in a separate field and all collectively storedin the one or more legacy databases; wherein any of the plurality ofselected health care data associated with the health care record havingthe same meanings is expressed in different formats; wherein theplurality of selected health care data the intermediary computer systemis configured to receive is of a type that is organized for use by thepayor but has not previously been subject to a normalized format; andwherein the normalized format is of a type that displays health caredata from one or more sources such that any health care data associatedwith a health care record having the same meaning will be expressed inthe same format despite any prior formatting; a staging database that ispart of the intermediary computer system and that is configured toreceive the plurality of selected health care data from the one or moreof the payor computer systems; wherein receipt of the plurality ofselected health care data by the intermediary computer from the one ormore health care payor computer systems allows initiation of processingof the plurality of selected health care data to the normalized format;a normalization system that interacts with the staging database and isconfigured to remodel the plurality of selected health care data intothe normalized format, the normalization system comprising: a rulesengine that establishes the predefined format and predetermines how eachof the plurality of selected health care data is to appear in itsrespective field for the participant; wherein fields in the normalizedformat that correspond to the fields containing the selected health caredata from the one or more legacy databases are identified; wherein anyof the plurality of selected health care data that is not expressed aspredetermined by the normalized format is remodeled so all the pluralityof selected health care data of the health care record is expressed aspredetermined by the normalized format becoming normalized data suchthat all normalized data expressing information having the same meaningnow expresses that meaning in the same format; and wherein the theplurality of selected health care data on the intermediary system isreplaced with normalized data; an audit database that is configured totrack remodeling of the selected health care data into normalized data;and wherein the intermediary system is configured to transfer thenormalized data over a data network to a participant computer system andback to the health care payor.
 2. The system of claim 1, wherein theintermediary computer system is configured to receive a request by theparticipant computer system that initiates extracting the health caredata from the payor computer system.
 3. The system of claim 2, whereinthe rules engine applies the normalized data to respond to the requestof the participant computer system.
 4. The system of claim 2, whereinthe rules engine determines whether the participant computer system isauthorized to receive the normalized data.
 5. The system of claim 2,wherein the normalized data is applied to respond to the request of apatient computer system.
 6. The system of claim 2, wherein the rulesengine applies the normalized data to respond to the request of aprovider computer system.
 7. The system of claim 1, wherein theparticipant computer system is configured to transmit a request that issent to the intermediary computer system that determines which healthcare data is to be extracted and normalized in order to respond to therequest.
 8. The system of claim 7, wherein the participant computersystem transmits the request and the intermediary system transmits thenormalized data to the participant computer system over the internet. 9.The computer system of claim 1, wherein the intermediary computer systemis configured to determine whether any of the plurality of health caredata is invalid and configured to transfer the invalid health care datato an invalid data database to be corrected.
 10. The system of claim 9,wherein any invalid health care data is evaluated to make the invalidhealth care data useable.
 11. The system of claim 1, wherein the rulesengine determines how the normalized data can be used.
 12. The system ofclaim 1, further comprising a medical administration system including aprocess of executing a medical test referral that includes transmittinga determination of the referral to the participant computer system whichis a health care provider, patient, employer, or payor.
 13. The systemof claim 12, wherein a result of a medical test is transmitted to atleast one receiver selected from the group consisting of the one or morepayors, the health care provider, another health care provider, apatient, and an employer.
 14. The system of claim 1, wherein the rulesengine defines relationships among the selected health care datanormalized to the predefined format pursuant to predeterminedinstructions to determine a response to a request.
 15. The system ofclaim 1, wherein the normalized data is used to respond to a request bya payor computer system.
 16. The system of claim 1, further comprising aprovider computer system that makes a request tat initiates extractingthe plurality of the selected health care data from the payor computersystem.
 17. The system of claim 1, wherein a payor computer system makesa request that initiates extraction of the selected health care datafrom the one or more payor computer systems.
 18. The system of claim 1,further comprising a medical administration system wherein the rulesengine refers a specialist, and is configured to transmit a referral tothe participant computer system which is a health care provider,patient, employer, or the one or more payors.
 19. The system of claim 1,further comprising a medical administration system including a processof executing a medical procedure referral that includes transmitting adetermination of the referral to the participant computer system whichis a health care provider, patient, employer, or payor.
 20. The systemof claim 1, wherein a medical health record can he generated from thenormalized data.